Applicants Must Be a US Citizen Or an Eligible Immigrant;

An Equal Housing Opportunity Provider

To qualify for housing from Prairie Harvest Mental Health, the applicant must meet the following criteria:

Applicants must be a US citizen or an eligible immigrant;

All household members must meet the qualifications, not just the head of household;

It is your responsibility to notify our office in writing if:

Your mailing address changes
Your family composition or size changes
You no longer wish to remain on our waiting list

NOTE: If PHMH mail is returned to us because of an incorrect address, your application will be removed from our waiting list(s), and you will need to reapply. If you have any questions regarding the application process, please call (701) 795-9143

Properties managed by Prairie Harvest Mental Health are limited to persons with serious mental illness.

All monies for the first month and security deposit will be due when the lease is signed. Security deposits for all the properties listed below are one month’s rent. Amounts listed are contract rents.

1. Limited to persons with serious mental illness.

Siewert Plains – 5450 6th Ave N(ProjectBased Voucher)
Rent - $325.00
Board - $8.00/day
Prairie Lodge – 525 Fenton Ave (ProjectBased Voucher)
Rent - $340.00
Lodge dues - $205.00
Stern Place – 519 University Ave(Project Based Housing Choice Voucher)
Rent - $542.00
801 S 10thStreet(Housing Choice Voucher)
Rent - $379.00

Tenant Selection Criteria: Rental and credit history will be reviewed. All applicants are also screened for: involvement in criminal activity and involvement in use of illegal drugs and/or abuse of alcohol.

Order of Selection:Prairie Harvest Mental Health selects applicants from the waiting list in accordance with the date and time the completed application is received in the office.

PRAC units managed by Grand Forks Housing Authority (GFHA): (Complete GFHA applications and submit to Prairie Harvest Mental Health).

Harvest Homes - PRAC (Project Rental Assistance Contract)
Harvest Lodge - PRAC (Project Rental Assistance Contract)

Applicants must meet the eligibility and/or tenant selection criteria established by the Grand Forks Housing Authority.

An Equal Housing Opportunity Provider

APPLICATION FOR OCCUPANCY

BE SURE TO ANSWER ALL QUESTIONS WITH COMPLETE AND ACCURATE INFORMATION OR INDICATE IF IT DOES NOT APPLY. FAILURE TO ANSWER ALL QUESTIONS WILL SIGNIFICANTLY DELAY THE PROCESSING OF YOUR APPLICATION OR DEEM YOU INELIGIBLE. WHERE NECESSARY, ADDITIONAL PAGES MAY BE ADDED.

I. APPLICANT & HOUSEHOLD MEMBERS – (Changes in family composition may effect selection date & eligibility)

Head of Household’s Name:

Current Mailing Address:
Street: Telephone #: ( )

Apartment/Unit #:Cell phone #: ( )

City, State, Zip Code: E-mail Address:

Yes No Do you require an interpreter? If yes, what language do you speak?
List the legal name of all household members who will be living in the assisted unit as it appears on their Social Security Card. Social Security Numbers are required for ALL members of the household. The Head of Household must be at least 18 years old. Use additional paper if necessary. (Do not leave this section blank or incomplete.)

Name
(First, Middle Initial, Last) / Relationship to Head / Date of Birth / Gender / Social Security # / Employment status or Name of School
HEAD

Yes No Do you expect any changes in family members or income within the coming 12 months?

Yes No The Head of Household is: Unmarried ; Married ; Widowed ; Divorced ; Separated

Yes No Was anyone in your household ever known under a different name (such as a maiden name) or Social Security number? If yes, list name(s) & number(s)
Yes No Not applicable If you have children, do they have parents not living in the household? If yes, please list names(s) address(es) of absent parent(s)

Yes No Not applicable Does an adult member of the household have physical custody of minors included in the household 50% or more of the year? If no, with whom is custody shared, & what percentage of the year do the children live in your household?

Yes No Are all members of the household U.S. citizens or nationals? If not explain

II. RESIDENCY HISTORY – (Do not leave this section blank or incomplete)

Provide where you have lived for the last 5 years including your current place of residence. Use additional paper if necessary.If you have not had a fixed, regular, and adequate night time residence you must provide information regarding where you have stayed in the last 5 years. If where you lived was with someone temporarily, list that person’s information under the Landlord information section. If you have not lived in the United States in the last 5 years please identify the Country of residence.

Dates of Residency / Applicant’s Address / Landlord Information
Start:
End: CURRENT / Name
Address
Telephone
Start:
End: / Name
Address
Telephone
Start:
End: / Name
Address
Telephone

Yes No Other than the residences listed above, has anyone in your household EVER lived in any other state? If yes, list who and their state(s) of residence:
Yes No Has anyone in the household EVER been evicted? If yes, please give date and address of eviction, landlord’s name and address, and reason(s) for eviction:
Yes No Does anyone in your household currently owe money to a landlord? If yes, give the name and address of the landlord:

III. INCOME

Income includes but is not limited to: wages, tips, commission, military pay, seasonal employment, self-employment, earnings from medical studies, TANF, child/spousal support, Social Security, SSI, veteran’s benefits, Unemployment, Workman’s Compensation, student financial aid (other than loans), Railroad Retirement, pensions, monetary contributions or gifts regularly received from persons not in the household, farm income, etc.

**If you are reporting that your household receives no income, the Head of Household must sign hereto certify that the family receives no form of income, cash, financial assistance or contributions of any type.
By signing, I certify that no one in my household receives any income.

Report ALL current income received by any member of the household. When listing wages from employment, be sure to include how much you are paid per hour and how many hours per week, on average you work(Ex: wage $8.00 X 40 hours per week). Please list Gross Income (Amount before deductions).

Household Member / Source of Income / List Wages OR Amount Received
Source:
Address: / $
How Often?
Source:
Address: / $
How Often?
Source:
Address: / $
How Often?

Yes NoDoes anyone outside of your household pay any of your bills or give you money? If yes who and how much:
Yes No Do you have a representative payee? If yes please name, address and phone number of Rep Payee:
Do you have a legal guardian? If yes please name, address and phone number of your legal guardian:

IV. ASSET INFORMATION

Answer Yes or No and identify ALL assets of every household member. Use additional paper if needed.
Yes No Does anyone in the household own any Real Estate (house, land, mobile home, etc.) If yes, provide Address & type of Real Estate: Market Value $ Annual Tax $ Current Mortgage Balance $ Annual Income earned $
Yes No Does anyone in the household own or hold any other property/asset as an investment? This does not include necessary items of personal property, interest in IndianTrustLands, and assets that are part of an active business operation. If yes, please describe and give value:
Yes NoHas anyone in the household disposed of any property or asset in the past two years for less than fair market value? If yes, please list type of asset, when it was sold, and the value:
Yes No Does anyone in the household own a car? If yes, Please list the following for each vehicle:

Model & Year _ License Plate # Model & Year License Plate #

V. CRIMINAL BACKGROUND –Use additional paper if necessary.

Yes NoHas anyone in your household EVER been convicted of or involved with the use, possession, production or distribution of a controlled or illegal drug? If yes, explain: Who? _When? Where? __ For What?
Yes NoIs any member of the household currently registered as a sex offender or subject to registration in any state? If yes: Who? State of registration? ______
Yes No Has anyone in the household EVER been involved in fraudulent activity against any government agency? If yes: Who? Explain:
Yes No Has anyone in your household EVER been involved in ANY type of criminal activity not specifically identified above? If yes: Who? _When? Where? For What? Charges? Conviction/Sentence?

SignatureDate

AUTHORIZATION

For Release and Exchange of InformationPrairie Harvest Mental Health

930 North 3rd Street

Grand Forks, ND 58203-2408

Phone: (701) 795-9143

Fax: (701) 772-5560

CONSENT

I authorize and direct the persons, agencies or organizations listed on this Authorization to release and exchange information with Prairie Harvest Mental Health as needed, for the purpose of determining my qualifications for housing. I understand and agree that this authorization or the information obtained with its use may be given to and used by Prairie Harvest Mental Health in administering and enforcing program rules and policies. I also consent for Prairie Harvest Mental Health to release information from my file about my rental history to HUD, credit bureaus, collection agencies, landlords and other PHAs. I understand that, depending on program policies and requirements, previous or current information regarding my household or me may be exchanged. I understand that this authorization cannot be used to obtain any information about me that is not pertinent qualifying for housing. Verifications, inquiries and exchange of information that may be requested, include but are not limited to:

Identity and Marital Status, Employment, Income and Assets, Residences and Rental Activity, Credit and Criminal Activity.

PERSONS, GROUPS OR INDIVIDUALS THAT MAY BE ASKED TO SUPPLY INFORMATION

Previous landlords (including Public Housing Agencies), Past and Present Employers, Veterans Administration, Welfare Agencies, Retirement Systems, Court and Post Offices, State Unemployment Agencies, Banks & other Financial Institutions, Schools and Colleges, Social Security Administration, Credit Providers and Credit Bureaus, Law Enforcement Agencies, Medical and Child Care Providers, Utility Companies, and Support and Alimony Providers.

CONDITIONS

I agree that a photocopy of this authorization may be used for the purposes stated above. The original or an electronic version of this authorization is on file with Prairie Harvest Mental Health and will stay in effect for fifteen months from the date signed. I understand I have a right to review my file and correct any information that I can prove is incorrect.

SIGNATURES

Head of Household (Print Name)Date

Guardian (Print Name) Date

X_ _

Adult Member (Print Name) Date

930 N. 3rd St. Grand Forks, ND 58203, 701-795-9143, FAX 701-772.5560,

3/31/17 updated